Understanding and managing the impact of the Covid-19 pandemic and lockdown on patients with multiple sclerosis

ABSTRACT

Introduction

Covid-19 has been sweeping over the world for more than a year. People with Multiple Sclerosis (MS) might be particularly vulnerable either for the disease iteself or for the ongoing immune treatment. The aim of this review is to understand the impact of the Covid-19 pandemic and lockdown on patients with MS and to provide evidence-based advice to ensure them a high standard of care even during the pandemic.

Areas covered

Literature search was conducted in the Scopus, Web of Science, Pubmed electronic databases, and articles reference lists to investigate the effect of Covid-19 on MS patients’ treatment, access to health-care services and mental-health.The search terms ‘multiple sclerosis’ AND ‘Covid-19’ were combined with each of the following term ‘disease modifying treatment,’ ‘steroids,’ ‘vaccination,’ ‘mental health,’ ‘stress,’ ‘quality of life,’ ‘management,’ ‘impact,’ ‘recommendations,’

Expert opinion

To ensure MS control during the pandemic, minimizing the risk of Covid-19 contagion, face-to-face visits may be implemented with televisits. Management of relapses and DMTs schedule should be adapted based on the specific benefit/risk ratio for each patient, considering disease activity, disability, comorbidities. Vaccination should be strongly recommended. Telerehabilitation and online psychological support programs should be encouraged to preserve motor performances and mental health.

KEYWORDS:

• Multiple sclerosis
• Covid-19
• disease-modifying treatment
• vaccination
• psychological stress
• management

Article highlights

• Standard of care for patients with MS has been deeply disrupted by Covid-19 related restrictions imposing limited access to in-person visits, MRI and laboratory tests, changes in the management of relapses, the use of DMTs, the access to rehabilitation facilities, and psychological support programs.

• Severe Covid-19 is more likely to occur in male individuals with MS, with advanced disability and comorbidities such as obesity, diabetes, and hypertension.

• To date, available data from a single study suggest that Covid-19 infection, regardless of its severity, is not associated with an increased risk of relapse shortly following infection; long-term studies are needed to investigate the late effect of Covid-19 on MS activity and progression.

• The risk of developing Covid-19 is higher in anti-CD20-treated and lower in patients on IFN-ß and GA relative to patients prescribed with all other DMTs for MS.

• IFN-ß, GA, and teriflunomide may be continued or prescribed as initial DMT during the pandemic; there are no specific indications to discontinue dimethyl-fumarate or S1P modulators (fingolimod, siponimod) unless persistent lymphopenia occurs. It has been suggested to delay dosing for cell-depleting therapies based on individual risk of relapse and infection; natalizumab extended 6-week dosing has been suggested, especially in high-risk patients (older, age, high disability, obesity, cardiopulmonary comorbidity).

• People with MS are encouraged to get the SARS-CoV-2 vaccine as soon as possible with a correct timing concerning the ongoing therapy; the risks of Covid-19 infection far outweigh any potential vaccine risk.

• In newly diagnosed people with MS, neurologists might consider starting S1P receptor modulators at least 2–4 weeks after patients’ vaccination.

• People with MS should delay the first course of ocrelizumab to receive the vaccine first. Patients should receive the vaccine 2–4 weeks or more before therapy start, while patients that recently had a course of ocrelizumab should receive the vaccine 12 weeks or more after the last DMT dose and resume ocrelizumab 4 weeks or more after receiving the II dose of the vaccine.

• People with MS should receive the Covid-19 vaccine 4 weeks or more before starting alemtuzumab; those already on alemtuzumab should consider receiving the vaccine 24 weeks or more after the last dose.

• People with MS should receive the Covid-19 vaccine 2–4 weeks or more before starting Cladribine; those already taking cladribine should consider receiving the vaccine 12 weeks or more after the last treatment dose.

• Overall, vaccination before starting depletive DMTs would be preferable to ensure the best immune response.

• Covid-19 vaccines are not likely to trigger an MS relapse or to impact long-term disease progression.

• The quality of life and mental health of people with MS have been negatively impacted by the pandemic. Alternative forms of support with digital tools should be encouraged.

Declaration of interest

G Abbadessa received travel grants from Novartis and Sanofi. L Lavorgna received travel grants, speaker honoraria, and consulting fees from Roche, Biogen, Sanofi, Genzyme, Merck, Novartis, Teva, and Almirall. S Bonavita received speaker honoraria and/or advisory board fee, travel grants from Novartis, Teva, Roche, Sanofi-Genzyme, Biogen-Idec, Merck-Serono, Mylan. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.